The first thing to get straight is
the distinction between physical dependence, dependence and abuse in regard to
substance use. The phenomenon of addiction is baffling enough in its own right
without the added confusions resulting from the imprecise and undefined usage of
terms. But there are other words which also require clarification: addiction,
psychological dependence and substance dependence. All of these concepts are
widely and sometimes carelessly used, reminding one of Humpty Dumpty's unique
approach to language:

"When I use a word," Humpty
Dumpty said in a rather a scornful tone, "it means just what I choose
it to mean -- neither more nor less.
"The question is," said Alice, "whether
you can make words mean different things."
"The question is," said Humpty Dumpty,
"which is to be master -- that's all."
Alice was too much puzzled to say anything, so after a
minute Humpty Dumpty began again.
"They've a temper, some of them -- particularly
verbs, they're the proudest -- adjectives you can do anything with, but
not verbs -- however, I can manage the whole lot! Impenetrability! That's
what I say!"Through
the Looking-Glass and What Alice Found There. Lewis Carroll.

Physical dependence is a normal and universal
result of the sustained consumption of alcohol and certain other drugs. After a certain period of
time everyone who takes the drug in a sufficient dose will experience a
withdrawal syndrome characteristic of the particular drug if intake is suddenly
stopped or markedly diminished. Drugs that cause definite physical dependence
include:

Alcohol

Barbiturates

Benzodiazepines

Caffeine

Nicotine

Opioids

The nature and severity of withdrawal symptoms from drugs
that cause physical dependence vary according to the specific drug, the
dose and duration of its usage, and the specific characteristics of the user.

Physical dependence is not addiction.Everyone who ingests enough of a substance that causes physical
dependence will develop such physical dependence, i.e. a withdrawal
syndrome if the substance is suddenly stopped or markedly decreased.
But only a minority of individuals who develop such physical dependence
will go on to become addicted to the substance. Addiction
is not physical dependence - though many of the drugs to which
people can become addicted are capable of causing physical dependence.

Cocaine induces in some individuals one of the most
powerful and difficult to treat addictions of all - but cocaine does not cause
physical dependence in its users.

The confusion of physical dependence(= causes a
withdrawal syndrome in everyone who takes enough of the substance for a long
enough time) with addiction(= a behavioral syndrome characterized by prolonged
excessive and harmful use of the substance) is one of the commonest and most
harmful errors of understanding in this area. The majority of laypersons as
well as a substantial number of physicians believe that
"addictiveness" resides in certain substances rather than in the
vulnerabilities of individuals exposed to those substances. But in fact only a
minority of persons exposed to drugs that cause physical dependence(= withdrawal
or discontinuation syndrome) go on to develop the behavioral syndrome of
addiction.

It is obvious that the vast majority of people who consume
alcohol, benzodiazepine tranquilizers(Valium like drugs) and opioids(narcotics)
do not become addicts. Yet all of these substances are capable of causing
definite and sometimes severe withdrawal syndromes.

Physical dependence simply means that if the substance
being used is suddenly stopped or markedly reduced, the user
develops certain specific withdrawal or discontinuation symptoms
in a pattern and course characteristic of that substance.

Addiction refers to a complex behavioral syndrome
that includes pathological salience(=abnormal importance of the substance),
obsession with obtaining and using the drug, excessive, prolonged and harmful
use despite adverse consequences, and the mental defense mechanisms of denial,
rationalization, minimization and justification. In the current official
diagnostic systems the word dependence is used in place of addiction,
further complicating and confusing the topic since this is by no means the same
thing as the physical dependence described above.

Thus in the current diagnostic systems alcoholism(alcohol
addiction) is called alcohol dependence. Benzodiazepine addiction is
called benzodiazepine dependence. And opioid(narcotic) addiction is
called opioid dependence. The general category for all of these is called
substance dependence.

The word dependence is thus being used in two
distinct ways:

1. In the sense of physical dependence(= capable
of causing a withdrawal syndrome) as described above; and

2. In the sense of addiction(=behavioral syndrome
of sustained, excessive and harmful use of a substance).

It is easy to see how confusion results from such dual but
distinct meanings of the same word, dependence. The matter is even more
complex because most of the drugs that are involved in the behavioral syndrome
of addiction(= substance dependence) are in fact capable of causing the
condition known as physical dependence(= capable of causing withdrawal
syndrome).

A maladaptive pattern of substance use leading
to clinically significant impairment or distress as manifested by three (or
more) of the following, occurring at any time in the same 12-month period:

Substance is often taken in larger amounts
or over longer period than intended

Persistent desire or unsuccessful efforts to
cut down or control substance use

A great deal of time is spent in activities
necessary to obtain the substance (e.g., visiting multiple doctors or
driving long distances), use the substance (e.g., chain smoking), or
recover from its effects

Important social, occupational, or
recreational activities given up or reduced because of substance abuse

Continued substance use despite knowledge of
having a persistent or recurrent psychological, or physical problem that
is caused or exacerbated by use of the substance

Tolerance, as defined by either:

need for increased amounts of the
substance in order to achieve intoxication or desired effect; or

markedly diminished effect with
continued use of the same amount

Withdrawal, as manifested by either:

characteristic withdrawal syndrome for
the substance; or

the same (or closely related) substance
is taken to relieve or avoid withdrawal symptoms

Evidence of tolerance, such that increased
doses of the psychoactive substance are required in order to achieve
effects originally produced by lower doses

A physiological withdrawal state when
substance use has ceased or been reduced, as evidence by: the
characteristic withdrawal syndrome for the substance; or use of the same
(or a closely related) substance with the intention of relieving or
avoiding withdrawal symptoms

Examination of the above diagnostic criteria for substance
dependence(addiction) discloses the complex nature of the behavioral syndrome of
addiction and easily distinguishes it from the far simpler phenomenon of
physical dependence, which is merely an occasional component of the addictive
syndrome.

The diagnostic criteria for substance dependence(=
addiction) are generally the same for all substances except for specific
differences in the nature of the withdrawal syndrome itself.

In the context of the current diagnostic criteria the
concept of substance abuse has a specific meaning, namely, a destructive
pattern of substance use, leading to significant social, occupational, or medical
impairment. Substance abuse may be thought of as problematic substance use
that does not rise to the level of substance dependence(addiction). By
definition, all substance dependence includes substance abuse. But substance
abuse may and sometimes does occur without the presence of the full substance
dependence(addiction) syndrome.

One final concept completes this complex and
tangled forest of competing definitions and ideas: the notion of psychological
dependence upon a substance. One may become psychologically dependent upon
anything from a security blanket to another person to a pharmacologically
inactive placebo(sugar pill). For whatever reason, the psychologically dependent
person believes that he cannot do without whatever it is that he happens to be
dependent upon. Thus any threat of loss or separation from the object of his
dependence will arouse anxiety and trigger activity intended to prevent loss of
the object. In this sense, substance dependence invariably includes
psychological dependence upon the substance - but psychological dependence may
be present without substance dependence or abuse.

II. Prescription Drug Abuse

Prescription drug abuse is the term commonly used
to describe the excessive and harmful usage problems that certain people have
with prescription medications, usually of the sedative-hypnotic(tranquilizer and
sleeping pill) class and the opioid(narcotic) class. Individuals who take too
much of such medications are said to be abusing medications. They can be
classified under the diagnostic criteria given above into substance abuse or
substance dependence(addiction) patterns. The term prescription drug abuse
commonly is used to refer to either or both groups and is thus still another
opportunity for conceptual confusion.

It is unfortunate that the terms abuse and
dependence possess a powerful moral resonance and also imply a specific
set of sociocultural norms and expectations. Many people in Western culture have
been brought up to believe that it is bad and weak to be dependent on anyone or
anything - period. The cultural ethos prizes and in some cases requires
independence rather than dependence. And of course the term abuse suggests
a variety of unprincipled, immoral and illegal behaviors. The very
language that is presently used to describe substance problems is thus saturated
with values, judgments and theories about what such problems represent and what
ought to be done about them.

Not all tranquillizers are candidates for
"abuse." It is customary to divide modern tranquillizers into two
groups: (1) major tranquillizers like Thorazine, Haldol, Risperdal,
Zyprexa and many others, none of them subject to "abuse," and (2) minor
tranquillizers like Valium, Xanax, Ativan, Tranxene and Klonopin, all of
them potentially "abusable."

Commonly abused narcotic pain medications include
those containing synthetic narcotics such as hydrocodone or oxycodone, e.g.
Lortab and Lorcet, Percodan, Vicodin, Percocet, as well as Demerol, Dilaudid,
codeine, methadone and Darvon-containing compounds. Morphine, while subject to
the same potential for abuse as the others, is less commonly prescribed for
routine outpatient use.

Sleeping pills(sedatives and hypnotics) that are
sometimes abused include Dalmane, Restoril, and Halcion. Older barbiturate
sleeping pills such as Nembutal, Seconal, and Tuinal were both extremely
dangerous in overdose and also highly prone to abuse, hence are seldom
prescribed any longer.

Soma(carisoprodol, a relative of meprobamate,
"Miltown" or "Equanil," the very first modern tranquillizer)
is a widely used skeletal muscle relaxer that is not uncommonly abused, usually
in conjunction with pain medications and/or tranquillizers.

Stimulants such as Ritalin and Dexedrine lend
themselves to abuse by some individuals.

It is worth noting that antidepressant drugs
(Prozac, Paxil, Zoloft and many others) are not liable to abuse. Despite their
capacity to lift certain types of depression, they do not provide abnormal
"highs" or euphoric experiences of the kind that abusable drugs often
do.

All of the medications listed above can be useful
and safe if used in the correct fashion. It is a mistake to condemn such
medications or to avoid entirely their use in appropriate circumstances simply
because a small minority of individuals become dependent upon them and abuse
them.

It is also a mistake, though a psychologically
important and revealing one, to confuse the normal or healthy requirement of a
sick person for a medication to remain well with that of the unhealthy and
abnormal dependence of the addict. A severe diabetic, for example, is
unquestionably "dependent" upon insulin in order to maintain correct
glucose metabolism; and an individual with congestive heart failure is certainly
"dependent" upon digitalis and a diuretic("water pill") in
order to maintain as much cardiac function and general physical function as
possible. There are people who are in fact bothered by such types of
"dependence" upon appropriate and necessary medications, but it is
obvious that their difficulties derive from denial of their underlying medical
condition and the reality of their impaired health rather than from any concern
about medication per se. For such people, the need to take medication
simply reinforces the unpleasant truth that they prefer not to think about,
namely, that they suffer from a chronic condition.

The simplest and most reliable way to distinguish
normal use of medications from their abuse is to consider whether they are
being used for a legitimate medical purpose in accordance with the directions of
a competent and ethical treating physician. Patients who take such medications
for the right reasons and in the right doses cannot be described as abusing
medications. They may and frequently do develop the syndrome of physical
dependence(= causes a withdrawal syndrome) on medications which are capable
of causing this - but the likelihood of proceeding to substance dependence(= the
behavioral syndrome of addiction) is small.

On the other hand, when prescription medications
are obtained in non-medical ways(from friends, family, or from sellers), when
they are taken for non-medical purposes, or when they are taken in a fashion or
quantity not recommended by a treating physician, such use can be correctly
classified as medication abuse. It is under these circumstances that the
possibility of medication dependence(addiction) is greatly enhanced.

Individuals with pre-existing addictive disorders
such as alcoholism(= alcohol dependence in the current diagnostic language) seem
to be more prone to the abuse of prescription medications than others. Personal
or social maladjustment, depression, personality disorder, or a family history
of addictive problems may predispose somewhat to prescription medication abuse.
Patients with chronic painful conditions such as recurrent headache or "bad
backs" may be at somewhat greater risk, especially when other risk factors
are also present. Individuals who normally experience a high level of stress or
discomfort and who lack the self-care skills to relieve such stress may find
quick and unanticipated relief in prescription medication originally given for a
transient or minor medical condition and thus attempt to prolong and increase
their usage of medication.

Among health care professionals such as
physicians, nurses, dentists and veterinarians prescription medication abuse and
dependence(=addiction) not uncommonly commences almost "by accident"
as the stressed, distressed, tired, and often depressed clinician takes a dose
of pain medicine or a tranquillizer to relieve a temporary physical discomfort
and discovers that there is an unexpected "bonus effect" in the relief
of mental and emotional tension, the soothing of depression, and the
augmentation of energy and drive. This effect is then actively pursued by taking
the no-longer-needed medication for a "non-medical" purpose, often
with gradual increase in frequency of use and quantity of consumption until the
full behavioral syndrome of addiction(= substance dependence) has set in and the
person has become preoccupied with obtaining and using the medication in amounts
far exceeding the normal dose and for reasons not related to the proper
therapeutic usage of the drug.

The same scenario often occurs in patients
prescribed medication by their physician for a legitimate medical purpose. The
patient finds that the medication relieves not only the symptom(s) for which it
was initially prescribed but also induces a desirable mood, level of energy, or
other positive and mental effect which can be reproduced by additional doses of
medicine even after the original legitimate medical reason for its use no longer
exists. Some patients may then continue to request medications from their
physician or from other physicians even though they no longer require them.
Usually the dose is gradually increased to levels far in excess of those
normally reached because the patient's system(principally the liver) becomes
increasingly able to detoxify the medication and higher doses are therefore
required to maintain the same effect. This escalating dosage effect is
particularly pronounced in the case of the narcotic pain relievers, which
routinely induce tolerance("immunity") to their effects with sustained
and regular usage.

The mental effects of prescription medications
vary considerably from person to person. Some people, for example, find that
narcotic pain relievers simply make them feel bad - so much so, at times, that
they would rather put up with the pain than take the medication. There are
innate differences in people as to how they are affected by such medications.

Some people, as described above, notice a
pleasant, soothing, relaxing or at times energizing effect of prescription pain
medications which tempts them to continue taking them long after the need for
them has passed. Such people exaggerate or even fabricate pain in order to
obtain more medications. They may begin going to multiple physicians to acquire
enough medication to meet their usually increased needs, as the effect of
tolerance means that higher and higher dosages are necessary to achieve the same
effect.

From the physician's standpoint patients
developing substance dependence fail to improve in the symptoms for which
medications were first prescribed. Indeed, their symptoms may appear to become
worse, thus necessitating higher and higher dosages of medication to control
them. Nothing else seems to work or provide relief. Patients may begin to call
in for refills early and to report prescriptions that have supposedly been lost
or stolen.

Whenever prescription medications are taken
frequently in excess of directions, when they are taken for reasons other than
those for which they were intended and prescribed, and when the patient begins
to be preoccupied with obtaining and consuming the medication, the likelihood of
medication abuse of dependence(= addiction) is high. Obtaining medications by
devious or unusual means is another indicator of serious difficulty. And
dishonesty, secrecy, lying, stockpiling and manipulating(for example,
exaggerating or inventing symptoms) to obtain medications are definite
indicators of medication abuse and dependence at an advanced and dangerous
stage.

By the time the full blown syndrome of medication
dependence(=addiction) has set in the patient has often tried unsuccessfully to
cut back or stop using the drug altogether. Repeated failures to attain these
goals is one of the most reliable indicators of addiction. For as Mark Twain
said about nicotine addiction, "It's easy to stop smoking. I've done it a
hundred times."

The medication dependent(=addicted) individual is
frequently like the character in "Alice in Wonderland" who had to run
as fast as he could just to stay in the same place. When addiction is firmly
established the chief job of the person is to meet the
requirements of the addiction for whatever substance is involved. Failure to
meet these requirements is met with the severe punishment of mental and physical
withdrawal. It is no longer so much a case of attaining positive results by
taking medication as it has become of avoiding negative results by making
certain that the medication is always available. Particularly in the case of
prescription drugs, to which easy access is restricted by the requirement for a
physician's prescription, the addicted individual may have to spend an amazing
amount of time and energy simply ensuring that he does not run out of
medication. This often involves multiple doctor visits, visits to emergency
rooms, and even phoning in illegal prescriptions or forging or altering
prescriptions.

Medication dependent(=addicted) persons
invariably experience and almost always manifest impairments in their thinking,
feeling and actions. Intermittent confusion, memory loss, impaired judgment,
personality change, emotional disturbance(depression, mood instability,
irritability), social withdrawal and physical incoordination and sluggishness
leading to falls, accidents and injuries are common. As time goes on the person
becomes less and less like their normal "pre-addiction" self and more
and more akin to the stereotypical substance addict. Ethical deterioration in
the form of dishonesty, secrecy, manipulation, lying and even stealing is a
frequent accompaniment of many advanced addictions. These behaviors contradict
the basic pre-addictive value structure of the individual and therefore cause
great inner conflict, dissonance, shame and guilt - all of which serve to fuel
the addictive process by increasing mental distress and the need for chemical
relief of suffering. A vicious circle is established from which the addict finds
it exceedingly difficult, sometimes impossible to break free without outside
assistance.

Narcotic pain relievers, taken in sufficient dose
for a sufficient period of time, all cause a specific opioid withdrawal syndrome
manifested by:l

Chills

Sweating

Runny nose and eyes

Abdominal cramps

Muscle pains

Insomnia

Nausea

Diarrhea

Insomnia

Anxiety and restlessness

Yawning

Drug craving

Fatigue

Dysphoria (unpleasant, painful mental state)

Despite its well-earned reputation for extreme
discomfort("cold turkey"), the pure opioid withdrawal syndrome, unlike
some cases of sedative/tranquillizer/alcohol withdrawal, is never a
life-threatening condition. Opioid withdrawal does not result in seizures. The
withdrawal syndrome resolves spontaneously without treatment in 1 - 2 weeks in
most cases, although brief and progressively diminishing recurrences of some
symptoms are occasionally observed for some time afterwards before finally
ceasing entirely.

2. Sedatives/Tranquillizers

Virtually all of the sedatives and tranquillizers
in common use today are members of the benzodiazepine family of drugs which
includes Valium, Xanax, Ativan, Klonopin, Tranxene, Dalmane, Restoril and
Halcion. The barbiturate family, because of its overdose lethality as well as
its proneness to abuse and dependence, is today far less widely used for routine
outpatient sedation and tranquillization than it was before the introduction of
the benzodiazepines. Barbiturates, benzodiazepines and alcohol all behave
similarly in their effects on the central nervous system and in the kinds of
withdrawal syndromes they produce. Any member of any class will substitute for
any member of another class in preventing its withdrawal syndrome when the
primary drug is halted. Thus Valium can substitute for phenobarbital which can
substitute for alcohol.

The sedative/tranquillizer/alcohol withdrawal
syndrome consists of:

Anxiety and restlessness

Insomnia

Elevated pulse, temperature and blood
pressure

Visual and tactile hallucinations

Confusion and disorientation (delirium
tremens, D.T.'s)

Grand mal convulsions

Under typical circumstances only a minority of
sedative dependent individuals will develop the full blown withdrawal syndrome,
which, however, is occasionally fatal. In general, the higher the dose and
the longer the use of the substance, the more likely the withdrawal syndrome is
to be severe and possibly dangerous. All symptoms are promptly suppressed by an
adequate dose of a benzodiazepine tranquillizer, which is the standard
detoxification treatment for such conditions. Decreasing doses of medication are
used when necessary and then discontinued as symptoms abate. The acute
withdrawal is usually complete in a week or less, but anxiety, insomnia, and
mood instability, although with drug craving and heightened risk of relapse may
persist for weeks or months afterward, gradually diminishing in most cases until
the individual is restored to his normal pre-addictive state.

Medical and psychiatric evaluation for
associated conditions and complications

Education about addiction, self-care and
recovery

Relief of stress and the development of a
healthy lifestyle

Psychosocial treatment and support, including
12 Step groups when appropriate

Simply discontinuing the substance(s), with or
without a brief period of medical detoxification, is often, though not always,
ineffective. The "stop-and-start" recurrent nature of the underlying
addictive process means that unless the addiction itself receives attention and
treatment it may well reassert itself again after a brief interval of abstinence
in which all superficially appears to be going well. The need for such ongoing
"recovery therapy" is especially pronounced in individuals with a past
or family history of substance dependence, and in those whose addiction has
progressed to an advanced stage characterized by elaborate and often illegal
drug-seeking behavior.

When substance dependence(= the behavioral
syndrome of addiction) appears within the context of a chronic psychiatric or
medical condition for which the offending drugs were originally indicated and
useful before addiction set in, medical management of such symptoms as remain is
obviously important and can sometimes be challenging. In many though
unfortunately not in all cases, relief of the addictive disorder actually
results in a diminution or disappearance of symptoms(chronic pain, intractable
headaches, anxiety, insomnia) for which the medications may have originally been
prescribed. When symptoms persist and require treatment it is important to
devise a plan that offers the maximum possible relief with the minimum risk of
relapse into addiction. Neglect of legitimate symptoms can predispose to relapse
if the affected individual feels there is no alternative but to return to the
drug(s) which first provided some relief.

A very high percentage(up to half in some
studies) of individuals developing substance dependence disorders also manifest
one or more psychiatric conditions, of which depression and anxiety
disorders are by far the commonest. Adult attention deficit disorder has
recently been recognized as a condition that may predispose to substance
dependence. In many cases the resort to prescription drugs actually began
as an unwitting attempt to "self-medicate" and relieve the symptoms of
such pre-existing conditions. Temporary relief of such psychiatric symptoms was
indeed obtained with narcotics and/or sedatives, but with the onset of substance
dependence(= the behavioral syndrome of addiction) these initial gains were lost
and were replaced by increased symptoms resulting from an escalating negative
interaction between the addictive and the psychiatric disorders.